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   Current UPMC employees must apply in HR Direct

Quality Assurance Reviewer III-Claims

Description

Shape the world of health care by joining UPMC! As a leader in the industry, we are committed to enhancing the lives of all who are a part of our community. Without our employees, we would not be able to innovate health care for our patients and health plan members. From hospitals to our corporate office, all UPMC employees impact our mission of creating life changing medicine. To continue our tradition of excellence, we are in search for a Quality Assurance Reviewer III to join this community as well.


Responsible for quality review and or internal audit of processed claims, including behavioral health claims and work flows. Performs higher level auditing functions, including peer review of audited claims and auditing to ensure Health Plan compliance for all lines of business. Assists in the development of QA department policies/procedures. Serves as policy and procedure expert for claims auditing functions. Retrieves, distributes and monitors random audit reports. Maintains QA department auditing and training tools. Provides training and assistance to QA staff. Interfaces with internal and external customers to meet or exceed service requirements and requests. Represents QA department at internal and external Health Plan meetings. Provides trending, analysis and reporting of auditing data to make recommendations for quality improvement.

Someone with claims processing experience or claims review experience would be preferred. Also, someone who has MC400 experience. 

Responsibilities:

  • Provides training to new QA Staff as needed.
  • Assists supervisor with research, resolution and response of error appeals.
  • Identifies errors trends to determine appropriate training needs and suggest modifications to policies and procedures.
  • Assists manager and supervisor in the development and revision of QA department policies and procedures.
  • Participates as required in special projects and other auditing activities.
  • Performs quality review on all types of claims, including behavior health claims, adjustments, checks and workflows using root cause analysis in accordance with company policies and procedures.
  • Maintain employee/insured confidentiality.
  • Serves as a QA department representative at designated Health Plan meetings as directed by supervisor.
  • Maintains or exceeds designated quality and production goals.
  • Serves as process expert for MC400 claims auditing function.
  • Develops and maintains auditing tools.
  • Participates in all training programs to develop a thorough understanding of the materials presented to the claim and service staff.
  • Provides trending, analysis and reporting of auditing data to make recommendations quality improvement.

 

Qualifications

Qualifications

  • Bachelor's degree or equivalent education and experience.
  • Five to seven (5-7) years of claims auditing experience required
  • Keyboard dexterity and accuracy. Ability to maintain designated production standards, multiple projects and tasks.
  • Extensive knowledge of medical terminology, ICD-9 and CPT-4 coding. Extensive knowledge of HMO, POS and PPO plans.
  • Extensive knowledge of coordination of benefits, subrogation, Medicare and Medicaid.
  • Detail oriented individual with excellent organizational skills. High degree of oral and written communication skills.
  • Intermediate proficiency with MS Office products and extensive PC skills.


Licensure, Certifications, and Clearances:
HIA - Health Insurance Associate preferred.MCP - Managed Care Professional preferred.CQA - Certified Quality Auditors preferred.


UPMC is an Equal Opportunity Employer/Disability/Veteran

Total Rewards

More than just competitive pay and benefits, UPMC’s Total Rewards package cares for you in all areas of life &emdash; because we believe that you’re at your best when receiving the support you need: professional, personal, financial, and more.

Our Values

At UPMC, we’re driven by shared values that guide our work and keep us accountable to one another. Our Values of Quality & Safety, Dignity & Respect, Caring & Listening, Responsibility & Integrity, Excellence & Innovation play a vital role in creating a cohesive, positive experience for our employees, patients, health plan members, and community. Ready to join us? Apply today.

   Current UPMC employees must apply in HR Direct